Vaginal Dryness Treatment

What is vaginal dryness?

Healthy vaginal tissue is moist, elastic and mildly acidic. This balance is maintained largely by oestrogen (the main female hormone). When oestrogen falls, the vaginal wall becomes thinner, loses its elasticity, produces less natural moisture and is easily irritated. Medically this is called vaginal atrophy (thinning and drying of the vaginal tissue).

When it is linked to the menopause, today it is called the genitourinary syndrome of menopause (menopause-related changes of the genital area and urinary tract; GSM for short). The name emphasises that the change affects not only the vagina but also the vulva, the urinary tract and the bladder. Up to half of women after the menopause have at least one complaint related to it.

Hot flushes may ease with time; vaginal dryness, however, usually does not go away on its own if untreated and tends to increase over the years.

What causes vaginal dryness?

• The menopause and the years just before it: the most common cause. As the ovaries make fewer hormones, the vaginal tissue thins. Surgical removal of the ovaries has the same effect.
• After childbirth and while breastfeeding: oestrogen stays low during breastfeeding; dryness usually settles as breastfeeding decreases and periods return to normal.
• Some medicines: medicines used in breast cancer treatment that suppress oestrogen or block its effect (anti-oestrogen medicines); injections that suppress ovarian hormones, used for conditions such as fibroids; some hormonal contraceptives; some allergy and depression medicines.
• Cancer treatment: chemotherapy (drug treatment for cancer) and radiotherapy (radiation treatment) to the pelvis can cause dryness by affecting the ovaries or the tissue directly.
• Sjögren's syndrome (an immune condition that affects the body's glands and causes a dry mouth and dry eyes).
• Smoking: reduces blood flow to the tissue and has a negative effect on oestrogen levels.
• Not enough arousal: too little arousal before intercourse, stress or relationship difficulties can reduce natural lubrication.
• Irritating products: scented soaps, shower gels, bubble baths, perfumed pads and vaginal douching (washing out the inside of the vagina) disturb the tissue's natural protection.

What are the symptoms?

• Dryness, burning, stinging and itching in the vagina and vulva
• Pain during intercourse — medically called dyspareunia (pain during intercourse) — and reduced lubrication
• Light bleeding or spotting after intercourse
• Needing to pass urine often, burning when passing urine and frequent urinary infections
• Discomfort that gets worse when sitting, walking or wearing tight clothes
• Lower sexual desire — often because intercourse has become painful

When should you see a doctor?

An assessment is worthwhile if dryness does not improve after a few weeks of regular moisturiser use, or if it affects your daily life or your sex life. In the following situations you should be examined without waiting:

• Any vaginal bleeding after the menopause
• Repeated bleeding after intercourse
• Unpleasant-smelling, coloured or unusual discharge
• Sores, white patches or itching that does not settle in the vulva

What happens at the examination?

• History: how long the complaints have lasted, your period and menopause status, breastfeeding, the medicines you take, any past cancer treatment and the care products you use.
• Gynaecological examination: the colour, thickness and elasticity of the vaginal wall, and whether it bleeds easily, are assessed. The acidity of the vagina may be measured.
• Ruling out infection: if there is discharge, a sample is taken to look for yeast or bacterial infection. For details, see the Vaginal Infection Treatment page.
• Ruling out skin conditions: if there are white, thin, itchy patches on the vulva, conditions such as lichen sclerosus (a skin condition that thins and whitens the skin of the genital area) are looked for.
• If a cervical screening (smear) test is due, it is planned at the same time.

How can vaginal dryness be eased? The steps of treatment

Current guidelines approach treatment in steps: first hormone-free support, then low-dose oestrogen applied in the vagina if that is not enough, and other options when needed. The right step is decided by looking together at how severe the complaints are, your medical history and your own preference.

1. Moisturisers and lubricants

• Vaginal moisturisers are used regularly, several times a week, whether or not you have intercourse. They add moisture to the tissue and ease everyday dryness and burning. Moisturisers containing hyaluronic acid belong to this group.
• Lubricants are used only during intercourse and reduce pain caused by friction. Water-based or silicone-based products are preferred; oil-based products can damage condoms.
• Because they contain no hormones, they are the first choice for women with a history of breast cancer as well.

For mild complaints this step is often enough. However, moisturisers do not restore thinned tissue; if complaints continue, the next step is considered.

2. Low-dose oestrogen applied in the vagina

If dryness does not improve with moisturisers, according to the 2020 position statement of The Menopause Society (formerly the North American Menopause Society, NAMS), the first-line medical treatment for menopause-related vaginal dryness is low-dose oestrogen applied in the vagina. It comes as a cream, a vaginal tablet or a ring.

• The oestrogen acts directly on the vaginal tissue and helps it regain its thickness, moisture and natural acidity.
• Very little reaches the bloodstream. According to guidelines it does not carry the risks of hormone therapy that acts on the whole body, and women who still have a womb do not need an additional hormone (progestogen).
• The effect starts within a few weeks; the full effect may take a few months. Complaints usually return when it is stopped, so it can be used long term.

3. Other prescription options

For some women who do not wish to, or cannot, use vaginal oestrogen, there are other prescription options: a hormone precursor applied in the vagina (DHEA; a substance the body can convert into oestrogen and male-type hormones) and a tablet taken by mouth that has an oestrogen-like effect on the vaginal tissue (ospemifene). Whether these medicines are licensed and available differs from country to country; whether they suit you is decided after an examination and a review of your medical history.

4. Energy-based methods (laser, radiofrequency)

Laser and radiofrequency applied to the vagina aim to heat the tissue and stimulate collagen production. Some studies have reported improvement in dryness and pain during intercourse; however, most studies are small and short, and long-term effectiveness and safety are not yet well known.

5. Pelvic floor physiotherapy

In women who have had painful intercourse for a long time, the muscles around the vagina tighten involuntarily in anticipation of pain, creating a cycle that makes the pain worse. Pelvic floor physiotherapy (exercises and techniques to relax and control the muscles at the base of the pelvis) is recommended alongside other treatments for women with pain during intercourse.

Does hormone therapy for the whole body also treat dryness?

Systemic hormone therapy (acting on the whole body) as tablets, patches or gel is used mainly for hot flushes and night sweats, and it can also help vaginal dryness. In some women, however, dryness persists; in that case vaginal oestrogen can be used in addition. Women whose only complaints are vaginal do not need treatment that acts on the whole body. For details, see the Treating the Menopause and Body-Identical Hormone Therapy pages, and for an overview of the menopause, the What the Menopause Is page.

What helps in daily life?

• Wash the genital area only on the outside, with lukewarm water or a mild, unscented cleanser.
• Do not douche or wash out the inside of the vagina; it disturbs the tissue's natural protection and its helpful bacteria.
• Avoid scented soaps, shower gels, bubble baths, perfumed pads and intimate deodorants.
• Choose loose, cotton underwear.
• Stopping smoking helps blood flow to the tissue.
• Regular sexual activity may help maintain blood flow and elasticity in the area; allow time for enough arousal before intercourse.

For a simpler summary of the topic, see our article vaginal dryness: causes, symptoms and current treatments.